Student initials: RMS

Date(s) of care: 05/31/08

Patient Information
Pertinent Medical History: Baby L was born 05/28/08 @ 11:18. Delievery CS for breech. Initial Assessment: weight was 6 lb, 5 oz.
(@0015, 05/31) length- 18.25” HC- 13.25”T-98.1F, resp-54; HR-66. Baby active; color is pink with olive undertones, good cry,
head normocephalic,fontanelles and sutures WNL.Milia present across nose. Hair is soft, black and sparse. Eyebrows and lashes
present, eyes and ears level, nostrils equal, no flaring observed. Sucking pads present. Palate intact, good suck reflex. Eyes
bright dark brown, + blink reflex, baby is responsive to sound and movement. No drooping or paralysis noted in face. Scelera
bluish-white. Ears are symmetrical, well-formed. No lesions noted. Clavicles straight and intact. BL lung expansion, Lungs clear
BL, nipples symmetric, flat. HR regular, no murmurs or thrills noted. Abdomen protruding, umbilical cord dry, no bleeding. Active
bowel sounds x 4 quad. No inguinal bulges, femoral pulses +1/4. Genitals symmetrical; pubis dark brown and engorged, scant
smegma present within labia. Buttocks symmetric, anus patent, no dimpling at coccyx. Symmetric buttock creases. All reflexes
charted as present. Apgar 8/9.
Occupation: newborn baby
Family History: FOC not present, great-grandmother has band.
Educational Level: none
Religion: none; mother is Baptist
Medications: none
Sociocultural considerations: family is of low socioeconomic status; may need referrals to outside agencies
ALLERGIES: NKA
Current lab findings: blood Type B+
DNR status: full CPR
Current diagnostic findings: normal, healthy newborn
 Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Rationale for interventions Evaluation
(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Include source and page numbers) (Client’s response to nursing actions
& progress toward achieving
goals & outcomes)
Subjective: Baby is calm,
soothes easily, does not
appear uncomfortable
Objective: Baby L’s axilla
temp: 98.1 F; skin warm and
dry
1
Cox’s Clinical Applications of Nursing Diagnosis; pg.141
2
Cox’s; pg.141
3
http://www.epilepsyfoundation.org/infants/neonatalonset.html
Risk for imbalanced
body temperature r/t
extreme of age (newborn
status)
Assess infant’s temp each Infants lack mature
Infant will maintain its hour thermoregulation. Temps too high Goal Met: Baby L’s temp. remains
body temperature between or too low can disrupt acid-base WNL for entire shift
97.0 and 99.0F for entire balance, causing seizures or
shock.1
shift
If temp is above 101F, take Infants are at risk for febrile
measures to bring temp to seizures r/t immature
normal range: thermoregulation and must be
o Administer safeguarded against further
antipyretics as sequelae.2
ordered
Signs of neonatal seizures
o Monitor and
include:
document related
symptoms with
specific regard to • Repetitive sucking
febrile seizures • Repeated extending of the
tongue
• Continuous chewing
• Continuous drooling
• Long pauses in breathing
(apnea)
• Rapid eye movements
• Blinking/fluttering of eyelids
• Fixation of gaze to one side
• Body aligned to one side
• Pedaling/stepping
movements of legs
• Paddling/rowing movements
of arms
• Rapid muscle jerks 3
 If temp is < 97.0F, take
measures to bring temp to
normal range:
o place Young infants cannot initiate
infant compensatory regulation of
under temperature and can become
warmer septic at body temps below 97.0F
4

Infants can become dehydrated

o or on under warmer if not carefully
monitored.5
mother’s
chest
under
blanket

Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Rationale for interventions Evaluation

4
Old’s Maternal and Newborn Nursing; pg.
5
Cox’s; pg.141
 (Supporting data)
Subjective:
MOC states “I have no milk
because I had a c-section”;
MOC is using S&S to
supplement feedings.
Objective:
Baby L is consuming 20-30 mL
of formula per feeding; MOC’s
breasts are very tubular in
shape, very little mammary
tissue present; cannot express
milk with pump. Baby’s weight
has remained constant since
birth (6 lb, 5 oz)
6
Cox’s; pg. 149
(NANDA diagnostic statement)
Ineffective
breastfeeding r/t
maternal breast
anomaly AEB need for
supplemental feedings
and no observable
maternal milk
production
(Realistic, timed, measurable)
Baby will feed four times
during shift,
supplementing with 20
mL of formula per feed
(Strategies or actions for care)
Assess a feeding for proper
technique
Determine effect of altered
breastfeeding pattern on
mother and infant by
spending 30 minutes talking
with mother. Observe
mother-infant interactions
and maternal feelings
expressed.
Measure I/Os
(Include source and page numbers) (Client’s response to nursing actions
& progress toward achieving goals
& outcomes)
Collect baseline data Baby L was able to consume 20mL
during four feedings
Maternal-infant response
provides important
information in determining
how serious the breastfeeding
issue is. This will dictate how
to approach the problem and
promote realistic follow-up.6
Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Rationale for interventions Evaluation
(Supporting data) (NANDA diagnostic (Realistic, timed, (Strategies or actions for care) (Include source and page (Client’s response to nursing actions
measurable) numbers) & progress toward achieving goals
statement) & outcomes)
Subjective:
Baby will remain free from Monitor vital signs every 4 Provides baseline and allows for Baby L remained free from infection
infection for duration of hours quick identifications of any
Risk for infection R/T hospital stay. deviations that could indicate
maturational factors and infection7
immature immune system
Institute aseptic precautions, Protects baby from pathogens
especially handwashing, around
Objective: infant.

patient is 3 day old infant

Teach MOC about infectious MOC was able to verbalize the

MOC will verbalize
measures to decrease
infection in her newborn by
end of shift
process, including routes, Provides basic knowledge for importance of proper handwashing
pathogens, environment and protecting newborn
host factors. Include specific
aspects of prevention:
• Wash hands often,
especially before
handling infant or
after changing her
diaper
• Do not allow sick
friends or family to
interact with infant

7
Cox’s pg. 54